Provider Demographics
NPI:1689864415
Name:VILLAGE OF GENEVA ON THE LAKE INC
Entity Type:Organization
Organization Name:VILLAGE OF GENEVA ON THE LAKE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FISCAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCKINLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-466-8197
Mailing Address - Street 1:10361 SPARTAN DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45215-1220
Mailing Address - Country:US
Mailing Address - Phone:800-962-1484
Mailing Address - Fax:513-772-4464
Practice Address - Street 1:4931 S WARNER DR
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:OH
Practice Address - Zip Code:44041-9719
Practice Address - Country:US
Practice Address - Phone:800-962-1484
Practice Address - Fax:513-772-4464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0683667Medicaid
OH000000155980OtherANTHEM
OH0683667Medicaid